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To the Editors:
It is with great concern and disquiet that I reread the article titled "Moral Distress of Staff Nurses in a Medical Intensive Care Unit" (November 2005: 523–530).
While acknowledging the limitations postulated by the authors regarding small sample size, I must take issue with the way in which moral distress is presented in terms of critical care nursing’s scope of influence. In the first paragraph of the article, moral distress is defined as "painful feelings and/or psychological disequilibrium . . . in which the ethically right course of action is known but cannot be acted upon" [emphasis added].
It seems to me that we professional nursing staff have a tremendous talent for giving away our power to others in critical situations. This impression, in my opinion, seems to be reinforced as I read further in the article. The top 5 items associated with moral distress all appear to relate to end-of-life care issues—this would be unsurprising; however, farther down the list, I note items such as "Carry out a work assignment for which I do not feel professionally competent" and "Ignore situations of suspected patient abuse by caregivers."
Unless I am very mistaken, and at least in the state in which I work, there are extensive and specific legal proscriptions against many of the behaviors mentioned as being sources of moral distress. Perhaps this should more greatly influence a nurse’s judgment as to whether to positively act, although the culture of the work environment in which they find themselves would seem to work against it. My point, in these instances, is that a distinction should be made between a true inability to act on the patient’s behalf when ethical integrity is seen as being jeopardized, and a potential lack of clarity and decisiveness on the part of the nurse regarding their more concrete obligations—moral confusion fueled by a belief that nurses supposedly have little or no power, when they are not only morally obligated but legally required to stand and be counted.
As regards the top 5 items in the list and their correlation to end-of-life issues, I would attempt to clarify by excerpting from Matzo et al.1 In that article, the following is stated as the policy of the American Nurses Association: "nurses may not deliberately act to terminate the life (of) any person, given Nursing’s social contract with society that is based on trust. It further states that while the nursing profession and its individual practitioners are committed to the patient’s right to self-determination, nurses are not obligated to comply with all requests."1
Furthermore, "Nurses need to develop the sensitivities and skills necessary to preserve the integrity of clinical care as well as their professional life. Nurses have the right to conscientiously object to participating in patient care situations that the nurse may find morally objectionable. The Code for Nurses and the Joint Commission on Accreditation of Healthcare Organizations...both support this right while recognizing the primacy to remain committed to patients entrusted to the clinician’s care."1
As a final point, I would like to address the assertion by Elpern et al that "Evidence suggests that patients and their families are not satisfied with end-of-life care in the ICU." Aside from the many complex and thorny issues regarding futility, inappropriate use of technology, and so on, I would suggest that satisfaction both for patients and their families, as well as professional nursing staff, may lie at least partially in the knowledge that their nurse is "on solid ground" as an advocate for patients; there should be no question in a patient’s mind as to what the nurse stands for, regarding first that patient’s rights and responsibilities and second the nurse’s legitimate sphere of influence. Otherwise, how can nurses claim to provide realistic options to patients in need when the same nurses so readily equivocate on their own standards?
Rockford, Ill
REFERENCES
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